Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis

Abstract

ObjectiveTo determine the relative efficacy of structured named diet and health behaviour programmes (dietary programmes) for prevention of mortality and major cardiovascular events in patients at increased risk of cardiovascular disease.DesignSystematic review and network meta-analysis of randomised controlled trials.Data sourcesAMED (Allied and Complementary Medicine Database), CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and ClinicalTrials.gov were searched up to September 2021.Study selectionRandomised trials of patients at increased risk of cardiovascular disease that compared dietary programmes with minimal intervention (eg, healthy diet brochure) or alternative programmes with at least nine months of follow-up and reporting on mortality or major cardiovascular events (such as stroke or non-fatal myocardial infarction). In addition to dietary intervention, dietary programmes could also include exercise, behavioural support, and other secondary interventions such as drug treatment.Outcomes and measuresAll cause mortality, cardiovascular mortality, and individual cardiovascular events (stroke, non-fatal myocardial infarction, and unplanned cardiovascular interventions).Review methodsPairs of reviewers independently extracted data and assessed risk of bias. A random effects network meta-analysis was performed using a frequentist approach and grading of recommendations assessment, development and evaluation (GRADE) methods to determine the certainty of evidence for each outcome.Results40 eligible trials were identified with 35 548 participants across seven named dietary programmes (low fat, 18 studies; Mediterranean, 12; very low fat, 6; modified fat, 4; combined low fat and low sodium, 3; Ornish, 3; Pritikin, 1). At last reported follow-up, based on moderate certainty evidence, Mediterranean dietary programmes proved superior to minimal intervention for the prevention of all cause mortality (odds ratio 0.72, 95% confidence interval 0.56 to 0.92; patients at intermediate risk: risk difference 17 fewer per 1000 followed over five years), cardiovascular mortality (0.55, 0.39 to 0.78; 13 fewer per 1000), stroke (0.65, 0.46 to 0.93; 7 fewer per 1000), and non-fatal myocardial infarction (0.48, 0.36 to 0.65; 17 fewer per 1000). Based on moderate certainty evidence, low fat programmes proved superior to minimal intervention for prevention of all cause mortality (0.84, 0.74 to 0.95; 9 fewer per 1000) and non-fatal myocardial infarction (0.77, 0.61 to 0.96; 7 fewer per 1000). The absolute effects for both dietary programmes were more pronounced for patients at high risk. There were no convincing differences between Mediterranean and low fat programmes for mortality or non-fatal myocardial infarction. The five remaining dietary programmes generally had little or no benefit compared with minimal intervention typically based on low to moderate certainty evidence.ConclusionsModerate certainty evidence shows that programmes promoting Mediterranean and low fat diets, with or without physical activity or other interventions, reduce all cause mortality and non-fatal myocardial infarction in patients with increased cardiovascular risk. Mediterranean programmes are also likely to reduce stroke risk. Generally, other named dietary programmes were not superior to minimal intervention.Systematic review registrationPROSPERO CRD42016047939

Beneficios del consumo de dieta mediterránea en individuos con elevado riesgo cardiovascular: un patrón que debe convertirse en el común denominador

“…Adicionalmente, se encontró que la adición de margarina de canola a la dieta mediterránea se asoció con la reducción hasta del 65% (IC 95%: 0.15 -0.82) de muerte por causa cardiovascular, y (40) hasta del 56% (IC 95%: 0.21 -0.92) por cualquier causa . (10) Finalmente, la evidencia más reciente y de mayor calidad, es la provista por Karam et al , quienes realizaron una revisión sistemática y red de meta-análisis, donde compararon siete programas dietarios y su asociación con evento cardiovascular y riesgo de muerte en individuos con elevado riesgo cardiovascular, incluyendo 40 ensayos controlados aleatorizados con un total de 35.548 individuos, demostrando que la dieta mediterránea, comparada a cualquiera de las otras, provee la mejor protección frente a mortalidad por cualquier causa (OR 0.72; IC 95%: 0.56 -0.92), mortalidad cardiovascular (OR 0.55; IC 95%: 0.39 -0.78), ictus (OR 0.65; IC 95%: 0.46 -0.93), y de infarto agudo de miocardio no fatal (OR 0.48; IC 95%: 0.36 -0.65). Este efecto, fue más pronunciado (10) en aquellos con mayor riesgo cardiovascular .…”

“…(10) Finalmente, la evidencia más reciente y de mayor calidad, es la provista por Karam et al , quienes realizaron una revisión sistemática y red de meta-análisis, donde compararon siete programas dietarios y su asociación con evento cardiovascular y riesgo de muerte en individuos con elevado riesgo cardiovascular, incluyendo 40 ensayos controlados aleatorizados con un total de 35.548 individuos, demostrando que la dieta mediterránea, comparada a cualquiera de las otras, provee la mejor protección frente a mortalidad por cualquier causa (OR 0.72; IC 95%: 0.56 -0.92), mortalidad cardiovascular (OR 0.55; IC 95%: 0.39 -0.78), ictus (OR 0.65; IC 95%: 0.46 -0.93), y de infarto agudo de miocardio no fatal (OR 0.48; IC 95%: 0.36 -0.65). Este efecto, fue más pronunciado (10) en aquellos con mayor riesgo cardiovascular . Y aunque la evidencia es moderada y sigue siendo heterogénea debido a la forma en la que se miden los desenlaces, la tendencia es marcada y plausible con los mecanismos celulares y moleculares que poseen estos macro y micronutrientes.…”

“…De forma interesante, evidencia muy reciente sugiere que, incluso, en individuos con elevado riesgo cardiovascular, es decir, con enfermedad cardiovascular aterosclerótica establecida, la dieta mediterránea tiene el potencial de disminuir el riesgo de mortalidad por todas las causas, así como de (10) infarto agudo de miocardio no fatal . Considerando la evolución de la evidencia en los patrones dietarios, así como de la necesidad de conocer qué tanto impactan las dietas viables en nuestro medio, sobre todo en aquellos con mayor riesgo de morbilidad y mortalidad por enfermedad cardiovascular, el objetivo de esta revisión consiste en exponer evidencia actualizada sobre los beneficios de la dieta mediterránea en individuos con elevado riesgo cardiovascular.…”

Effectiveness of Interventions for Changing More Than One Behavior at a Time to Manage Chronic Conditions: A Systematic Review and Meta-analysis

“…Behavior change interventions can play a role in preventing exacerbations of chronic conditions and minimizing their symptoms, by supporting individuals to reduce their behavioral risk factors (e.g., stop smoking), increase protective behaviors (e.g., increase physical activity), and/or follow behavioral advice (e.g., medication adherence [ 4 ]). Despite the multiple behaviors indicated for the management of chronic conditions, to date, most rigorously evaluated behavior change interventions have focused on promoting single behavior change [ 5–8 ] and related impact on clinical outcomes [ 6 , 9 ]. Analyzing whether multiple health behavior change (MHBC) interventions lead to behavioral change is an important first step to understand which behaviors are driving the improvements in clinical outcomes.…”

Mediterranean diet for cardiovascular disease: an evidence mapping study

“…Recent research suggests that adhering to the MD significantly reduces the risk of CVD compared with other structured diets ( 6 ) . For instance, the low-fat diet focuses on reducing overall fat intake to achieve lower daily energy consumption.…”